Columbia Manor Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbia, Missouri.
- Location
- 2012 Nifong Boulevard, Columbia, Missouri 65201
- CMS Provider Number
- 265778
- Inspections on file
- 23
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Columbia Manor Health & Rehabilitation during CMS and state inspections, most recent first.
Staff failed to administer medications as ordered and did not document reasons for holding multiple medications for a cognitively intact resident with several chronic conditions, including hypertension, renal failure, hyperlipidemia, and prior stroke. Review of physician orders and MARs over several months showed numerous instances where daily and BID medications such as antihypertensives, anticoagulants, supplements, pain medication, and GI agents were marked as held without documented justification or new MD orders. A CMT reported that medications were sometimes held for low BP, loose stools, or the resident not feeling well, believed that MD orders were not always needed to hold certain drugs even without parameters, did not recall notifying the MD, and did not document reasons for the holds, contrary to facility policy requiring medications to be given as prescribed and concerns to be communicated to the prescriber.
A resident who was cognitively intact with anxiety and depression, and prescribed Ativan but not Oxycodone, was given another resident’s Oxycodone by a CMT, contrary to facility policy requiring verification of the right resident and medication before administration. The resident reported receiving two small white pills, feeling unwell, and later being told that 10 mg of Oxycodone had been administered instead of Ativan. Although facility policy required that medication errors be documented in the chart, reported, and investigated, record review showed no documentation of the error, no investigation records, and no notation in the resident’s progress notes for the date of the incident, despite the administrator’s expectation that such information be recorded.
Staff failed to follow facility policy requiring prompt notification of a change in condition and treatment refusals. A resident on hospice for a short stay was found with a lump on the forehead of unknown cause, which an LPN assessed but did not report to a physician or the resident’s representative. On a separate occasion, the same resident refused all scheduled medications, including aspirin, midodrine, diazepam, propranolol, senna, tamsulosin, and carbidopa-levodopa, without any documented notification to the attending physician, hospice physician, hospice staff, or the resident’s representative. In subsequent interviews, the LPN acknowledged forgetting to notify anyone, and the administrator, resident representative, attending physician, and hospice physician all stated they had not been informed and would have expected notification.
Facility staff did not report an allegation of bruises and injuries of unknown origin for a resident to DHSS within the required 24-hour timeframe, as required by the facility’s abuse investigation and reporting policy. A resident’s representative twice informed the DON and the administrator that the resident returned home with a lump on the forehead, a laceration above the ear, bruising under the arm and on the side, and genital excoriation, without specifically alleging abuse or neglect. Despite these reports, the allegation of injuries of unknown origin was not submitted to DHSS until more than 48 hours after it was first reported to facility staff.
Staff failed to complete and document required skin assessments for a hospice patient admitted for a short stay with Parkinsonism, essential tremors, and A-fib. An LPN documented a lump on the patient’s forehead, but no follow-up skin assessment was recorded in the EMR after this change or prior to discharge, despite facility expectations and standard nursing protocol for head-to-toe and skin assessments with new skin changes and before discharge. After the patient returned home, the representative reported additional skin concerns, including a forehead lump, laceration above the ear, bruising to the side/underarm, and genital excoriation, none of which were documented by facility staff.
Facility staff did not notify the attending physician after a cognitively impaired resident, who required extensive assistance, fell in the shower and sustained a head injury. The DON responded, initiated neurological checks, and relied on hospice staff to notify the family and hospice nurse practitioner, but did not follow policy requiring physician notification. The care plan lacked documentation of fall risk assessment or interventions, and nurse's notes did not show physician notification.
Facility staff did not provide a required discharge notice for a resident transferred to the hospital and subsequently refused to allow the resident to return when the hospital determined admission was unnecessary, citing inability to meet care needs. Documentation and interviews confirmed the absence of a discharge notice and noncompliance with facility policy.
Staff failed to provide access to the emergency medication kit (E-Kit) for qualified personnel, resulting in multiple newly admitted residents not receiving their prescribed evening and bedtime medications. The facility's policy lacked guidance on E-Kit use, and staff did not document missed doses in progress notes. Interviews revealed confusion and lack of awareness among leadership regarding responsibility for granting E-Kit access.
Staff did not implement Enhanced Barrier Precautions due to lack of education, communication, and absence of a facility policy, resulting in two residents with wounds not having appropriate PPE available in their rooms and staff providing care without required gowns or gloves.
The facility failed to implement complete water system management policies, risking Legionella growth. Observations showed overdue ice machine filter changes and lack of air gap in drainage. The maintenance director was unaware of necessary procedures, and the administrator relied on their expertise without verification.
Facility staff failed to maintain a clean and homelike environment, with observations of unclean and damaged areas in resident rooms, including dark substance buildup on floor grout, gouges on bathroom floors, and rusted door frames. Interviews revealed lapses in reporting and addressing these issues, with maintenance requiring corporate approval for repairs.
The facility failed to develop comprehensive person-centered care plans for three residents, missing critical interventions for dementia care, behavior management, and activity preferences. Despite having a policy for care planning, the plans did not reflect the residents' medical histories or preferences. Staff interviews confirmed the need for care plans to include specific behaviors and updates, which were not present.
Facility staff failed to document weights for multiple residents and did not follow dietician recommendations for a resident with a diabetic foot ulcer. Despite orders for regular weight checks, records showed missing documentation over several months. Interviews revealed a lack of awareness and follow-up on these issues, contributing to the deficiency.
Two residents were unsafely propelled in wheelchairs without footrests, leading to a deficiency in accident hazard prevention. One resident with Alzheimer's and Parkinson's had their feet contacting the floor, while another with multiple conditions had their feet gliding across the floor. Staff admitted to not using footrests due to oversight and acknowledged the importance of using them to prevent injuries.
The facility failed to obtain informed consent for the use of bed side rails for six residents, despite a policy requiring such consent. Observations showed residents using side rails without documented consent in their medical records. Interviews with staff, including the MDS Coordinator and DON, revealed a lack of awareness about the consent requirement, leading to this deficiency.
The facility failed to ensure that ten nurse aides completed their CNA training within the required four months of employment. Despite the facility's policy, logistical challenges such as distant testing centers and filled local sites delayed the process. The DON and administrator acknowledged the issue, and nurse aides expressed frustration over the delays.
Facility staff failed to monitor and document the effectiveness and side effects of psychotropic and antipsychotic medications for several residents, leading to deficiencies in care. Residents were prescribed multiple medications without appropriate diagnoses or documentation of monitoring. Interviews with staff revealed a lack of adherence to facility policies on medication use and monitoring.
The facility did not comply with regulations by charging two NAs for CNA training and certification expenses through paycheck deductions. The Missouri Department of Health and Senior Services form showed a charge of $850.00 for training. Interviews revealed that NAs were informed of this requirement upon application, and one NA had not been reimbursed. The DON and administrator confirmed the practice, citing new ownership policies.
Facility staff failed to document the administration or refusal of the pneumococcal vaccine for three residents, despite having a policy requiring such documentation. The DON and care plan nurse cited challenges in maintaining accurate records, including difficulties in obtaining information from hospitals during the admission process.
Facility staff failed to consistently document the code status for two residents, leading to discrepancies between Full Code and DNR statuses. One resident had conflicting documentation between the nurse's notes, Physician Order Sheet, and an OHDNR form. Another resident's records showed inconsistencies between the Admission MDS, baseline care plan, and comprehensive care plan. Staff interviews revealed a lack of coordination between nursing and social services in verifying and updating code statuses.
A resident requiring hemodialysis did not receive proper care and monitoring before and after treatments due to facility staff's failure to conduct ongoing assessments and communicate with the dialysis clinic. The facility's policy lacked guidance on necessary assessments, and the resident's medical records did not document hemodialysis treatments. Interviews with staff revealed confusion and oversight in managing the resident's care.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
Facility staff failed to administer medications as ordered and failed to document reasons for holding medications for one cognitively intact resident with multiple chronic conditions, including hypertension, renal failure, hyperlipidemia, and a history of stroke. The resident’s physician orders in January included multiple daily and BID medications such as amlodipine, atorvastatin, cranberry, melatonin, pantoprazole, potassium chloride, spironolactone, thiamine, vitamin D3, cetirizine, apixaban (Eliquis), house shakes, gabapentin, and lactulose. Review of the January MAR showed numerous instances where these medications were marked as held on specific dates without any documented reason or corresponding physician orders to hold them. Similar issues continued in February, when gabapentin and spironolactone were held on several dates without documentation of the reason or evidence of new physician orders, and in March, when spironolactone and ondansetron were held without documented justification or physician authorization. During an interview, the CMT who documented the held medications stated they did not recall why the hold code was used multiple times for the resident and explained that, in practice, medications might be held if blood pressure was low, if residents had loose stools, or if they were not feeling well. The CMT further stated that whether the physician needed to be contacted depended on the reason for holding the medication, and that they believed they did not need orders to hold blood pressure medications or stool softeners even when no parameters were included in the original orders. The CMT reported not recalling notifying the physician about holding medications for this resident and acknowledged not documenting the reasons for holding them. The facility’s medication administration policy required medications to be administered as prescribed and for staff to contact the prescriber or physician if a dosage was believed to be inappropriate or associated with adverse consequences, but the records and interviews showed this process was not followed for this resident. Complaint #2799285
Significant Medication Error and Lack of Documentation After Wrong Drug Administered
Penalty
Summary
Facility staff failed to ensure residents remained free from significant medication errors when a Certified Medication Technician (CMT) administered one resident’s prescribed medication to another resident. The facility’s Administering Medications policy, revised April 2019, required staff to verify resident identity using methods such as checking identification bands, photographs, and, if necessary, confirming identity with other personnel, and to check the medication label three times to ensure the right resident, medication, dose, time, and route. Despite these requirements, CMT A reported giving one resident another resident’s Oxycodone instead of the ordered Ativan. The resident’s physician order sheet did not contain any order for Oxycodone, and the resident was assessed as cognitively intact with diagnoses of anxiety and depression. The resident reported receiving two small white pills from CMT A, then feeling “really funny,” and later being informed by a nurse that 10 mg of Oxycodone had been given instead of Ativan. The facility’s policy also required that medication errors be documented, reported, and reviewed by the QUAPI committee, and that such errors be documented in the resident’s chart with details of what happened, when it happened, corrective actions taken, and when the family and physician were notified, as well as monitoring and documentation of adverse reactions. However, review of the resident’s progress notes and facility-provided records for the date of the incident showed no documentation of a medication error or any facility investigation related to the error. The administrator stated there had been one medication error for this resident but did not know the details due to being on leave and acknowledged there was no proof of what the prior management nurse had done regarding the investigation. The resident reported that staff called the physician and monitored blood pressure after the error and that CMT A apologized, but the lack of corresponding documentation and investigation records demonstrated the facility’s failure to follow its own medication administration and error-reporting policies.
Failure to Notify Physician and Representative of Change in Condition and Medication Refusals
Penalty
Summary
Facility staff failed to notify the physician and resident representative of changes in a resident’s condition and treatment status as required by facility policy. The facility’s policy on Change in a Resident’s Condition or Status, revised 02/2021, directed staff to promptly notify the resident, attending physician, and resident representative of changes in medical or mental condition, discovery of injuries of unknown source, significant changes in condition, and refusal of treatment or medications two or more consecutive times. For one resident admitted from home with hospice services for a planned five-day stay, staff documented an incident in which a CNA alerted an LPN to a lump on the resident’s left forehead. The LPN assessed the resident as alert and oriented, with a lump present, no discoloration, no pain or discomfort, and no other identified injuries. The incident report and medical record contained no documentation that the physician or resident representative were notified of this potential injury of unknown source. The same resident’s POS listed multiple scheduled medications, including aspirin, midodrine, diazepam, propranolol, senna, tamsulosin, and carbidopa-levodopa. The MAR showed that on one day, the resident refused all of these scheduled medications. There was no documentation that the physician, hospice physician/staff, or resident representative were notified of the medication refusals. In interviews, the administrator stated staff could not determine the cause of the forehead lump and acknowledged an expectation that the nurse notify the on-call physician, hospice physician, and resident representative of both the lump and the medication refusals. The LPN involved stated he/she did not know what caused the lump and admitted he/she should have notified the physician and resident representative but became busy and forgot. The resident representative, attending physician, and hospice physician each reported they had not been notified of the lump or the medication refusals and stated they would have expected such notification.
Failure to Timely Report Injuries of Unknown Origin to DHSS
Penalty
Summary
Facility staff failed to report an allegation of bruises and injuries of unknown origin for one resident to the Department of Health and Senior Services (DHSS) within the required 24-hour timeframe. The facility’s abuse investigation and reporting policy, revised 07/2017, required that alleged violations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property be reported immediately, but not later than 24 hours if the alleged violation did not involve abuse with serious bodily injury. The resident, who had been admitted from home for a planned five-day stay and then discharged back home, had a documented resident representative. The representative first reported to the DON that, after returning home, the resident had an abrasion to the left side, a laceration approximately 0.5 inches above the left ear, bruising under the left armpit, and a lump to the back, but did not specify abuse or neglect or accuse anyone. The next day, the resident representative made a second report to the administrator, again describing a lump to the left forehead, a laceration above the left ear, bruising to the left side/underarm, and excoriation to the genitals. Despite these reports, the facility did not notify DHSS within 24 hours of the initial allegation of bruises and injuries of unknown origin. The DON acknowledged that, based on the information received from the resident representative and staff interviews, DHSS should have been notified within 24 hours of the initial report. The administrator also acknowledged that staff should have made an initial report to DHSS within the required timeframe but did not do so, and the DHSS complaint/facility self-report database contained no report from the facility until more than 48 hours after the allegations were first reported to facility staff.
Failure to Complete and Document Required Skin Assessments
Penalty
Summary
Facility staff failed to meet professional standards of quality by not completing and documenting required skin assessments for a resident who developed a lump on the forehead and was later discharged. The resident, admitted from home for a planned five-day stay with hospice services, had diagnoses including Parkinsonism unspecified, essential tremors, and atrial fibrillation. An incident report documented by an LPN noted a lump on the resident’s left forehead with no discoloration, no pain, and no identified injuries. However, the electronic medical record from the date of the incident through discharge contained no documentation that a skin assessment was completed following the identification of the lump. Additionally, there was no documented skin assessment prior to the resident’s planned discharge, despite interviews indicating that it was standard protocol and expectation for nurses to complete a head-to-toe and skin assessment on admission, with any identified skin changes, and prior to discharge. The DON, an LPN responsible for the discharge assessment, the administrator, and the LPN who identified the lump each acknowledged in interviews that a skin assessment should have been completed and documented in these circumstances. After discharge, the resident’s representative reported multiple skin issues, including a lump on the forehead, a laceration above the left ear, bruising to the left side/underarm, and genital excoriation, which were not documented in the facility’s records.
Failure to Notify Physician After Resident Fall with Head Injury
Penalty
Summary
Facility staff failed to notify the attending physician following a significant change in condition for a resident who experienced a fall with a head injury. According to the facility's policy, staff are required to promptly notify the resident, their attending physician, and the resident's representative of any changes in medical or mental condition, including accidents or incidents. In this case, a cognitively impaired resident, who required extensive assistance with bathing and was being assisted by a hospice aide, fell in the shower room, resulting in a raised, purple area above the right eye. The DON was notified and responded to the incident, initiated neurological checks, and assessed the resident, but did not notify the attending physician as required by policy. Interviews revealed that the DON relied on the hospice nurse to notify the family and hospice nurse practitioner, and believed that hospice staff would determine the next steps for a resident on hospice care. However, both the administrator and corporate nurse confirmed that facility staff are responsible for notifying the attending physician in the event of a fall, especially one involving a head injury. The care plan for the resident did not document fall risk assessment or interventions for falls, and the nurse's notes lacked documentation of physician notification after the incident.
Failure to Provide Discharge Notice and Allow Resident Return After Hospital Transfer
Penalty
Summary
Facility staff failed to provide a required discharge notice for a resident who was transferred to the hospital. The resident was initially admitted and then transferred to the hospital due to fluid leakage from the skin. Documentation shows that after the hospital determined there was no reason to admit the resident and requested the facility to arrange for the resident's return, facility staff refused to allow the resident to return, stating they could not meet the resident's care needs. The facility's policy requires notification of the resident's physician, the receiving facility, preparation of a transfer form, and notification of the resident's representative or family, but there was no evidence that a 30-day discharge or emergency discharge notice was provided in this case. Interviews with the Social Service Director and the administrator confirmed that the decision not to allow the resident to return was made by the administrator, and that no discharge notice was issued because staff were focused on transferring the resident and did not anticipate the resident's return. Review of the electronic medical record confirmed the absence of the required discharge notice, indicating noncompliance with discharge procedures and regulatory requirements.
Failure to Provide E-Kit Access Results in Missed Medication Administration
Penalty
Summary
Facility staff failed to maintain professional standards of practice by not ensuring that qualified staff had access to the facility's emergency medication kit (E-Kit), resulting in the failure to administer prescribed medications to three newly admitted residents. The facility's Medication Pass Policy did not include guidance on administering medications from the E-Kit, and staff did not document missed medication administration in the residents' progress notes as required. For each of the three residents, review of their Medication Administration Records (MARs) showed that evening and bedtime doses of multiple prescribed medications were not given on their admission or re-admission dates, with staff noting only to 'see progress notes,' which lacked any documentation of the missed doses. The residents affected included one with high cholesterol and depression, another with hypertension and depression, and a third with cognitive impairment, cerebral vascular accident, and hemiplegia. Each had physician orders for multiple medications, including antihypertensives, muscle relaxants, antidepressants, anticoagulants, and cholesterol-lowering agents. The medications were not administered as ordered due to staff not having access to the E-Kit, and there was no documentation in the progress notes to explain or address the missed doses. Interviews with facility staff revealed that the process for granting E-Kit access was unclear and not consistently implemented. The DON, who was new to the facility, was unaware of who was responsible for setting up E-Kit access. A Certified Medication Technician (CMT) reported not having access since starting employment, and the administrator was unaware that some CMTs lacked access. The President of Clinical Operations confirmed that the DON and pharmacist could set up E-Kit access but was not aware that staff had been unable to administer medications due to lack of access.
Failure to Implement Enhanced Barrier Precautions and Ensure PPE Availability
Penalty
Summary
Facility staff failed to implement Enhanced Barrier Precautions (EBP) as required, resulting in a lack of staff education and communication regarding which residents required EBP. The facility did not have an EBP policy in place, and staff were not consistently informed about the need to use personal protective equipment (PPE) during high-contact care activities for residents with wounds or indwelling medical devices. Observations revealed that PPE, such as gowns and gloves, was not available in close proximity to the rooms of two residents with wounds, and signage indicating required PPE was absent. Staff interviews confirmed that some CNAs were unaware of EBP requirements and had not received adequate communication or training on the policy. For one resident with multiple unstageable pressure ulcers and physician orders for wound care, staff entered the room to provide incontinence care without donning gowns, and no PPE cart was present outside the room. Another resident developed a new wound, and staff again provided care without using gowns or having PPE readily accessible. Multiple staff members reported confusion about EBP, citing a lack of clear communication and insufficient PPE availability. The facility's census at the time was 37 residents.
Deficiency in Water System Management for Legionella Prevention
Penalty
Summary
The facility staff failed to develop and implement complete policies and procedures for the inspection, testing, and maintenance of the facility's water systems, which are crucial for inhibiting the growth of waterborne pathogens such as Legionella. This deficiency was identified through observation, interview, and record review, revealing that the facility's water management program lacked documentation of monthly water heater flushing, a critical control measure. The facility census was 37 with a capacity of 52, indicating a significant number of residents potentially at risk. During the Life Safety Code tour, it was observed that the facility contained two ice machines for resident use, one of which had a drainage tube without an air gap, a necessary feature to prevent contamination. Additionally, the ice machine filter was overdue for replacement, as it was last changed in December 2022, contrary to the manufacturer's instructions to replace it every six months. The maintenance director admitted to not being aware of the requirement for an air gap in the ice machine drain and was unsure why the filter had not been changed. Interviews with the maintenance director and the administrator revealed a lack of awareness and understanding of the necessary procedures for maintaining the water systems. The maintenance director was unaware of the need to flush water heater tanks as a Legionella control measure and maintained water temperatures between 105 and 120 degrees Fahrenheit, which may not be sufficient to inhibit bacterial growth. The administrator relied on the maintenance director for expertise but was not sure if inspections included checking for an air gap in the ice machine drain or if the water heater flush was being conducted as required.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility staff failed to maintain a clean, comfortable, and homelike environment for residents, as evidenced by multiple observations of unclean and damaged areas in resident rooms. Observations on two separate days revealed a buildup of a dark substance on the floor tile grout lines in several occupied rooms, gouges on bathroom floors, and dark dried smears on bathroom wall tiles around toilets. Additionally, there were large gouges and rough edges on bathroom doors, rusted bathroom door frames, and cracked sink countertops with rough edges. Interviews with facility staff, including CNAs, the Maintenance Director, and the Director of Nursing, indicated that while staff are expected to report damaged areas to the Maintenance Director and housekeeping is responsible for cleaning, there were lapses in addressing these issues. The Maintenance Director acknowledged awareness of some damages but cited the need for corporate office approval for repair expenses. Housekeeping staff stated that resident rooms are cleaned daily, and issues like smears should be addressed immediately, yet the observations showed otherwise.
Deficiency in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and implement comprehensive person-centered care plans for three residents out of a sample of ten, despite having a policy in place since December 2016 that outlines the requirements for such care plans. The policy mandates that care plans should be derived from a thorough analysis of comprehensive assessments, include measurable objectives and timeframes, and reflect the resident's personal and cultural preferences. However, the care plans for the residents in question did not meet these standards. Resident #9's care plan, dated January 25, 2024, lacked interventions for dementia care, behavior management, pain management, and risk of bleeding associated with anticoagulant and antiplatelet use, despite the resident's complex medical history, including a stroke, dementia, and anxiety, and a comprehensive medication regimen. The MDS Coordinator acknowledged the absence of these interventions, citing the resident's lack of behaviors and signs of dementia as reasons for their exclusion. Resident #33's care plan did not address the resident's social, cognitive, or activity needs, despite severe cognitive impairment and a history of serious medical conditions. Similarly, Resident #143's care plan failed to include activity preferences, smoking safety, and fall interventions, even though the resident had severe cognitive impairment, a history of falls, and specific activity preferences. Interviews with facility staff, including the MDS Coordinator, RN, and DON, revealed a consensus that care plans should include specific behaviors, triggers from MDS assessments, and updates with changes in resident conditions, but these were not reflected in the care plans reviewed.
Failure to Document Weights and Follow Dietician Recommendations
Penalty
Summary
The facility staff failed to meet professional standards of care by not obtaining and documenting weights for five residents and not following up on dietician recommendations for one resident. The facility's policy required weights to be measured on admission and monthly, with documentation in the resident's record. However, the records for several residents showed missing weight documentation over several months, indicating a failure to adhere to the policy. Resident #1, who was cognitively intact and had diagnoses including anemia and kidney disease, had a physician's order to be weighed monthly, but no weights were documented from January to May 2024. Similarly, Resident #12, with diagnoses such as thyroid disorder and dementia, was supposed to be weighed weekly after admission and then monthly, but the records lacked documentation for several weeks and months. Resident #17, with severe cognitive impairment and Alzheimer's, had no documented weights for April or May 2024, and Resident #33, with severe cognitive impairment and multiple diagnoses, also lacked weight documentation for three months. Resident #142, who had a diabetic foot ulcer and was admitted in April 2024, was not weighed as ordered after readmission in May 2024. Additionally, dietician recommendations for this resident, including supplements and monitoring, were not followed up on. Interviews with the DON, dietician, LPN, and NA revealed a lack of awareness and follow-up on weight documentation and dietician recommendations, contributing to the deficiency.
Deficiency in Safe Wheelchair Propulsion
Penalty
Summary
Facility staff failed to safely propel two residents in wheelchairs, leading to a deficiency in ensuring a safe environment free from accident hazards. The facility did not have a specific wheelchair propulsion policy. Resident #17, who has Alzheimer's and Parkinson's disease, was observed being propelled by a CNA without foot pedals, causing the resident's feet to make contact with the floor. The CNA acknowledged the oversight, citing the resident's leg contractures as the reason for not using footrests. Similarly, Resident #8, who has a history of stroke, dementia, aphasia, seizures, depression, and respiratory failure, was also propelled by a CNA without footrests, resulting in the resident's feet gliding across the floor. The CNA admitted forgetting to attach the footrests as they were not with the wheelchair. Interviews with the LPN, DON, and the administrator confirmed that staff are educated on the importance of using footrests to prevent potential injuries, and they acknowledged their responsibility for resident safety.
Failure to Obtain Informed Consent for Bed Side Rails
Penalty
Summary
The facility staff failed to obtain informed consent for the use of bed side rails for six residents, despite the facility's policy requiring such consent. The policy, dated December 2016, mandates that staff obtain consent from the resident or their legal representative before using side rails. Observations and interviews revealed that residents were using side rails without documented consent in their medical records. For instance, Resident #3, who required moderate assistance with bed mobility and was totally dependent for transfers and toileting, was observed with a side rail in the raised position on multiple occasions without a signed consent. Similarly, Resident #9, who was cognitively intact and required supervision for transfers, was also using side rails without documented consent. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), indicated a lack of awareness regarding the requirement for consent for side rail use. The MDS Coordinator mentioned that therapy evaluates residents for safety and need for side rails, and the information is then passed to the DON to obtain a signed form. However, the DON was unaware that consents were required, and the administrator believed consents should be collected upon admission. This lack of awareness and failure to follow the facility's policy resulted in the deficiency of not obtaining informed consent for the use of side rails for the sampled residents.
Failure to Complete CNA Training Within Required Timeframe
Penalty
Summary
The facility failed to ensure that ten out of ten nurse aides completed the required nurse aide training program within four months of their employment. The facility's policy, dated May 2019, mandates that nurse aides must be certified within 120 days of employment. However, a review of the facility's active employee list revealed that all ten sampled nurse aides, hired between January 2023 and August 2023, were still listed as Certified Nurse Aide (CNA) in training, exceeding the four-month requirement. Interviews with the nurse aides and the Director of Nursing (DON) highlighted issues such as the distance to testing centers and the rapid filling of nearby testing sites as reasons for the delay in completing the training. The Director of Nursing acknowledged the struggle to complete CNA training due to logistical challenges, and the administrator confirmed awareness of the issue, citing filled testing sites as a barrier. Despite offering transportation to alternate testing sites, the problem persisted. Nurse aides expressed frustration over the delays, with one aide mentioning a change of ownership and test center problems as contributing factors. The facility census at the time was 37, and the deficiency was identified through interviews and record reviews conducted by surveyors.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility staff failed to ensure proper monitoring and documentation of psychotropic and antipsychotic medications for several residents, leading to deficiencies in care. Specifically, five out of seven sampled residents were not monitored for adverse reactions or the efficacy of their medications. Additionally, three of these residents did not have an appropriate diagnosis documented for the use of certain medications. This lack of monitoring and documentation is contrary to the facility's policy, which requires staff to gather and document information about a resident's behavior, mood, and medical condition to justify the use of such medications. Resident #1, who was cognitively intact and diagnosed with depression, was prescribed multiple medications, including Citalopram, Mirtazepine, Seroquel, and Trazodone. However, there was no documentation in the medical record indicating that staff monitored the effectiveness or side effects of these medications. Similarly, Resident #9, who was also cognitively intact and diagnosed with stroke, dementia, and anxiety, was prescribed a range of medications, including Lithium, Abilify, Buspirone, Cymbalta, Lorazepam, and Trazodone, without documentation of monitoring for effectiveness or side effects. The report also highlights the case of Resident #143, who was severely cognitively impaired and received multiple medications, including Clonazepam, Hydroxyzine, Seroquel, and Trazodone, without an appropriate diagnosis or care plan direction for their use. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed a lack of awareness and adherence to the facility's policy on medication monitoring and documentation. The staff acknowledged that non-pharmacological interventions should be tried before medication use and that appropriate diagnoses should be documented for all medications, not just antipsychotics.
Non-compliance with CNA Training Payment Regulations
Penalty
Summary
The facility failed to comply with federal, state, and local laws and professional standards by not providing financial payment for Certified Nurse Aid (CNA) training and certification expenses for two Nurse Aides (NAs) out of two sampled staff. The Missouri Department of Health and Senior Services On Site Visit Evaluation Instrument for Nurse Aid Training form indicated that the facility charged NAs $850.00 through paycheck deductions to complete a CNA training course and certification test. Additionally, the facility's Sponsorship Plan Reimbursement Agreement required NA staff to sign an agreement to pay for half of the cost of CNA training through payroll deduction. Interviews with the NAs revealed that they were informed upon application that they would be required to pay for CNA training and certification, with payments deducted from their paychecks. One NA mentioned not being reimbursed by the facility and not yet being a CNA. The Director of Nursing acknowledged awareness of the charges for training, noting that under previous ownership, the facility paid for the training and was later refunded by the state. The administrator confirmed the practice of charging NAs for training and certification costs as mandated by the new facility owners.
Failure to Document Pneumococcal Vaccine Administration or Refusal
Penalty
Summary
The facility staff failed to document the administration or refusal of the pneumococcal vaccine for three residents out of a sample of seven, despite having a policy in place since August 2016. This policy mandates that residents be assessed for vaccine eligibility upon admission and offered the vaccine within thirty days unless contraindicated or previously vaccinated. Documentation should include the date of administration or refusal, along with specific details if the vaccine is given. However, the medical records for the three residents, aged 88, 81, and 73, did not contain any documentation regarding the receipt or refusal of the vaccine. Interviews with the Director of Nursing (DON) and the care plan nurse revealed challenges in maintaining accurate vaccine records. The DON acknowledged difficulties in keeping up with vaccine documentation and was unsure about the status of the mentioned residents. The care plan nurse indicated that obtaining vaccine information from hospitals during the admission process can be challenging, often requiring multiple follow-ups. Despite these efforts, the necessary documentation was not found in the residents' medical records, indicating a lapse in following the established policy.
Inconsistent Documentation of Residents' Code Status
Penalty
Summary
The facility staff failed to consistently document the code status of residents, specifically for two residents out of a sample of four. Resident #39 was admitted with a Full Code status documented in the nurse's progress note, Physician Order Sheet, and Baseline Care Plan. However, an Outside the Hospital Do Not Resuscitate (OHDNR) form, signed by the resident's guardian and attending physician, indicated a DNR status. The Director of Nursing acknowledged that the DNR orders were not entered into the system, which was an oversight after the forms were signed. Resident #143 was assessed with severe cognitive impairment and had conflicting documentation regarding their code status. The Admission MDS and Physician Order Sheet indicated a Full Code status, while the baseline care plan showed a Do Not Resuscitate status. The comprehensive care plan lacked any direction for advanced directives. The Social Service Designee was unaware of this discrepancy but believed the resident was a DNR. Interviews with staff revealed that the charge nurse and social services were responsible for entering and verifying code status, but inconsistencies in the process led to discrepancies in the residents' medical records.
Failure to Provide Adequate Hemodialysis Care
Penalty
Summary
The facility staff failed to provide adequate care and services for a resident requiring hemodialysis. The deficiency involved the lack of ongoing assessments of the resident's condition and monitoring for complications before and after dialysis treatments. Additionally, there was a failure in communication and collaboration with the dialysis clinic. The facility's policy on End-Stage Renal Disease did not include directions for pre and post-dialysis assessments or collaboration with the dialysis clinic. The resident's medical records, including the Admission Minimum Data Set (MDS), Physician's Order Sheets (POS), care plan, and Treatment Administration Record (TAR), lacked documentation of hemodialysis treatments and necessary assessments. Interviews with facility staff, including an LPN, the MDS Coordinator, the Director of Nursing (DON), and the administrator, revealed a lack of clarity and responsibility regarding the resident's hemodialysis care. The MDS Coordinator admitted to an oversight in listing hemodialysis on the MDS and care plan. The DON and administrator acknowledged the absence of pre and post-dialysis assessments and communication with the dialysis clinic, attributing the responsibility to the nursing staff. The deficiency highlights a systemic issue in the facility's processes for managing residents requiring hemodialysis.
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Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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